DONATION AFTER CARDIAC DEATH PLAN Diagnosis Weight Allergies Patient Care Core Body Temperature Monitoring Maintain body temp 96-99 degrees Farenheit. Utilize Hyper/Hypothermia blanket prn Insert Gastric Tube Nasogastric - NG Orogastric - OG Gastric Tube to Suction Method: Low Intermittent Suction Communication Notify Nurse (DO NOT USE FOR MEDS) All orders must be approved by the primary team. Notify Nurse (DO NOT USE FOR MEDS) Cover accuchecks with Sliding Scale Insulin Protocol, moderate dose. If 2 accuchecks are over 180, begin the Insulin Drip Plan to keep blood gulcose 120-180. Notify Nurse (DO NOT USE FOR MEDS) Discontinue tube feedings. Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed..medication Management Start date If 2 Accuchecks are over 180, begin the Insulin Drip Plan to keep blood glucose 120-180. vancomycin 1,000 mg, IVPB, ivpb, q12h, Infuse over 90 min piperacillin-tazobactam 3.375 g, IVPB, ivpb, q6h heparin 30,000 units, IVPush, inj, ONE TIME Give on call to the OR. furosemide 100 mg, IVPush, inj, ONE TIME Give on call to the OR. mannitol 25 g, IVPush, inj, ONE TIME Give on call to the OR. Hormonal Therapy Protocol - Initiation Page 1 of 10
DONATION AFTER CARDIAC DEATH PLAN 40 meq, IVPB, ivpb, ONE TIME, Infuse over 1 hr Mix in 250 ml. Give ONLY if most recent potassium level is below 4. Infuse over 1 hour. Administer Hormonal Therapy Protocol in the following order: 1)-KCl replacement (if ordered). Allow to infuse completely. 2)-levothyroxine 20 mcg bolus. 3)-hydrocorti sone 100 mg IVPush 4)-D50W 25g IVPush 5)-insulin regular 20 units IVPush 6)-levothyroxine continuous infusion levothyroxine 20 mcg, IVPush, inj, ONE TIME Administer Hormonal Therapy Protocol in the following order: 1)-KCl replacement (if ordered). Allow to infuse completely. 2)- levothyroxine 20 mcg bolus. 3)-hydrocortisone 100 mg IVPush 4)-D50W 25g IVPush 5)-insulin regular 20 units IVPush 6)- levothyroxine continuous infusion ***Select both hydrocortisone orders below*** hydrocortisone 100 mg, IVPush, inj, ONE TIME Administer Hormonal Therapy Protocol in the following order: 1)-KCl replacement (if ordered). Allow to infuse completely. 2)- levothyroxine 20 mcg bolus. 3)-hydrocortisone 100 mg IVPush 4)-D50W 25g IVPush 5)-insulin regular 20 units IVPush 6)- levothyroxine continuous infusion hydrocortisone 50 mg, IVPush, inj, q6h Start 6 hours after the initial hydrocortisone bolus. glucose (D50) 25 g, IVPush, syringe, ONE TIME Administer Hormonal Therapy Protocol in the following order: 1)-KCl replacement (if ordered). Allow to infuse completely. 2)- levothyroxine 20 mcg bolus. 3)-hydrocortisone 100 mg IVPush 4)-D50W 25g IVPush 5)-insulin regular 20 units IVPush 6)- levothyroxine continuous infusion insulin regular 20 units, IVPush, inj, ONE TIME Administer Hormonal Therapy Protocol in the following order: 1)-KCl replacement (if ordered). Allow to infuse completely. 2)- levothyroxine 20 mcg bolus. 3)-hydrocortisone 100 mg IVPush 4)-D50W 25g IVPush 5)-insulin regular 20 units IVPush 6)- levothyroxine continuous infusion Hormonal Therapy Protocol-Levothyroxine levothyroxine 200 mcg/500 ml 1/2 NS IV, Do NOT Titrate Administer Hormonal Therapy Protocol in the following order: 1)-KCl replacement (if ordered). Allow to infuse completely. 2)- levothyroxine 20 mcg bolus. 3)-hydrocortisone 100 mg IVPush 4)-D50W 25g IVPush 5)-insulin regular 20 units IVPush 6)- levothyroxine continuous infusion Continued on next page... Page 2 of 10
DONATION AFTER CARDIAC DEATH PLAN Start at rate: mcg/hr Hormonal Therapy Protocol - Vasopressin vasopressin 1 units, IVPush, inj, ONE TIME Give prior to starting vasopressin continuous infusion. vasopressin 40 units/100 ml NS - Fixed R (vasopressin 40 units/100 ml NS - Fixed Rate) IV Final concentration= 0.4 unit/ml. Provider order required for ALL rate changes. Notify provider for any of the following: Urine output less than or equal to 50 ml/hr OR greater than 300 ml/hr, AND/OR sodium level is less than or equal to 135 mmol/l. Start at rate: units/hr Laboratory BB Blood Type (ABO/Rh), Comment: LifeGift blood typing BB Antibody Screen BB Clot to Hold BB PRBC Blood Order Quantity: 2 BB Plasma Order Quantity: 2 CBC with Differential CBC with Differential Comprehensive Metabolic Panel Comprehensive Metabolic Panel DIC Panel DIC Panel Magnesium Level Magnesium Level Phosphorus Level Page 3 of 10
DONATION AFTER CARDIAC DEATH PLAN Phosphorus Level Bilirubin Direct Bilirubin Direct LDH LDH GGT GGT Amylase Level Amylase Level Lipase Level Lipase Level Hemoglobin A1C, Comment: Draw before starting continuous insulin infusion Urinalysis Urine, Culture Urine Culture Blood Blood,, Comment: Draw 2 bottles, each one from a seperate site. Culture Sputum with Gram Stain...Additional Orders Sliding Scale Insulin Regular Guidelines ***Initiate the Electrolyte Med Plan (unless serum creat greater than 2) To keep Potassium greater than 4, Mag greater than 1.6, and Phos greater than 2.5*** Page 4 of 10
INSULIN DRIP PLAN UMC Health System Patient Care Insulin Drip Protocol ***See Reference Text*** LOW Target Blood Glucose 100 mg/dl 120 mg/dl 140 mg/dl HIGH Target Blood Glucose 120 mg/dl 140 mg/dl 160 mg/dl POC Blood Sugar Check q1h, by fingerstick, CVL, or arterial line. DO NOT alternate sites without Physician approval. Communication Notify Provider (Misc) (Notify Provider of Results) Reason: Blood Glucose less than 60 or greater than 200, also notify if two consecutive BG s less than 70. Notify Provider (Misc) Reason: If other physicians order insulin subq, IV, or in TPN, feedings are started, stopped, or changed, or if other physicans turn off drip for any reason. Notify Nurse (DO NOT USE FOR MEDS) Obtain Serum Blood Glucose if Accucheck is less than 40 or greater than 450. Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. insulin R 100 units/100 ml NS IV Insulin Drip Formula: (BG - 60) x 0.03 = number of UNITS insulin/hour BG = Current Blood Glucose 0.03 = "multiplier" 100 units, Every Bag glucose (D50) 25 g, IVPush, syringe, as needed, PRN low blood sugar Calculate D50W dose by the following formula: (100-BG) x 0.3 = milliliters of D50W to be given IV Push. Then divide by 2 to get grams of D50W ***If Levemir dose is greater than 60 units, the dose should be split in half and given BID. One injection should not be more than 60 units.*** insulin detemir units, subcut, inj, Daily To obtain Levemir dose perform the following: Average the last 8 hours of the insulin drip to units per hour. Multiply this times 20. Administer this amount of Levemir subcutaneously 2 hours PRIOR to discontinuing drip. Dose to be reassessed by physician every 24 hours. Continued on next page... Page 5 of 10
INSULIN DRIP PLAN UMC Health System units, subcut, inj, BID To obtain Levemir dose perform the following: Average the last 8 hours of the insulin drip to units per hour. Multiply this times 20. Administer this amount of Levemir subcutaneously 2 hours PRIOR to discontinuing drip. Dose to be reassessed by physician every 24 hours. Page 6 of 10
ELECTROLYTE MED PLAN Communication When placing the protocol order, do NOT order any meds unless you need IMMEDIATE electrolyte replacement therapy. Electrolyte Replacement Protocol ***See Reference Text*** Electrolyte Replacement Protocol (IV Potassium Replacement) Electrolyte Replacement Protocol (IV Sodium Phosphates Replacement) Electrolyte Replacement Protocol (IV Potassium Phosphates Replacement) Electrolyte Replacement Protocol (IV Magnesium Replacement) Electrolyte Replacement Protocol (Oral Potassium Replacement) Electrolyte Replacement Protocol (Oral Phosphates Replacement) Electrolyte Replacement Protocol (Oral Magnesium Replacement) Electrolyte Replacement Protocol (Aggressive Treatment Option) IV Solutions Replacement orders should only be used in patients with a serum creatinine less than 2 mg/dl, BUN less than 30 mg/dl, and urinary output greater than 30 ml/hr An infusion pump is required for all electrolyte infusions Only the selected electrolytes will be replaced per protocol IV POTASSIUM REPLACEMENT: *****Central line administration***** 20 meq, IVPB, ivpb, ONE TIME, Infuse over 1 hr, *Repeat serum potassium level 2 hours after the total replacement is completed. CENTRAL LINE 20 meq/hr - [Serum Potassium 3.6-3.9 mmol/l] 40 meq, IVPB, ivpb, ONE TIME, Infuse over 2 hr, *Repeat serum potassium level 2 hours after the total replacement is completed. CENTRAL LINE 20 meq/hr - [Serum Potassium 3.1-3.5 mmol/l] 60 meq, IVPB, ivpb, ONE TIME, Infuse over 3 hr, *Repeat serum potassium level 2 hours after the total replacement is completed. CENTRAL LINE 20 meq/hr - [Serum Potassium 2.6-3 mmol/l] 80 meq, IVPB, ivpb, ONE TIME, Infuse over 4 hr, [Notify Physician if Serum Potassium < 2.6 mmol/l] **Repeat serum KCL level 2 hrs after the total replacement is completed. **ECG monitoring required for infusion rates > 10 meq/hr. **Check CENTRAL LINE 20 meq/hr - [Serum Potassium less than 2.6 mmol/l - notify physician] *****Peripheral line administration***** 20 meq, IVPB, ivpb, ONE TIME, Infuse over 2 hr, *Repeat serum potassium level 2 hours after the total replacement is completed. PERIPHERAL LINE 10 meq/hr - [Serum Potassium 3.6-3.9 mmol/l] Page 7 of 10
ELECTROLYTE MED PLAN 40 meq, IVPB, ivpb, ONE TIME, Infuse over 4 hr, *Repeat serum potassium level 2 hours after the total replacement is completed. PERIPHERAL LINE 10 meq/hr - [Serum Potassium 3.1-3.5 mmol/l] 60 meq, IVPB, ivpb, ONE TIME, Infuse over 6 hr, *Repeat serum potassium level 2 hours after the total replacement is completed. PERIPHERAL LINE 10 meq/hr - [Serum Potassium 2.6-3 mmol/l] 80 meq, IVPB, ivpb, ONE TIME, Infuse over 8 hr, [Notify Physician if Serum Potassium < 2.6 mmol/l] *Repeat serum KCL level 2 hours after the total replacement is completed. *ECG monitoring required for infusion rates > 10 meq/hr. *Check Mg l PERIPHERAL LINE 10 meq/hr - [Serum Potassium less than 2.6 mmol/l - Notify Physician] IV SODIUM PHOSPHATES REPLACEMENT: *****Use when only phosphorus needs replacement***** sodium phosphate 15 mmol, IVPB, ivpb, ONE TIME, Infuse over 2 hr, Repeat serum phosphorus level 6 hours after infusion is completed. [serum phosphorus 2-2.5 mg/dl] sodium phosphate 30 mmol, IVPB, ivpb, ONE TIME, Infuse over 4 hr, Repeat serum phosphorus level 6 hours after infusion is completed. [serum phosphorus 1-1.9 mg/dl] sodium phosphate 45 mmol, IVPB, ivpb, ONE TIME, Infuse over 6 hr, [Notify physician if serum phosphorus less than 1 mg/dl] *Repeat serum phosphorus level 6 hours after infusion is completed. [serum phosphorus less than 1 mg/dl - notify physician] IV POTASSIUM PHOSPHATES REPLACEMENT: *****Use when phosphorus AND potassium need replacement***** potassium phosphate 15 mmol, IVPB, ONE TIME, Infuse over 2 hr, **Repeat serum phosphorus level 6 hours after infusion is completed. **Each 15 mmol of phosphorus contains 22 meq of potassium. [serum phosphorus 2-2.5 mg/dl] potassium phosphate 30 mmol, IVPB, ONE TIME, Infuse over 4 hr, **Repeat serum phosphorus level 6 hours after infusion is completed. **Each 15 mmol of phosphorus contains 22 meq of potassium. [serum phosphorus 1-1.9 mg/dl] potassium phosphate 45 mmol, IVPB, ONE TIME, Infuse over 6 hr, [Notify Physician if serum phosphorus < 1 mg/dl] **Repeat serum phosphorus level 6 hours after infusion is completed. **Each 15 mmol of phosphorus contains 22 meq of potassium. [Notify Physician if serum phosphorus less than 1 mg/dl] Page 8 of 10
ELECTROLYTE MED PLAN IV MAGNESIUM REPLACEMENT: magnesium sulfate 2 g, IVPB, ivpb, ONE TIME, Infuse over 60 min, Repeat serum magnesium level 2 hours after the infusion is completed. [serum magnesium level 1.3-1.6 mg/dl] magnesium sulfate 3 g, IVPB, ivpb, ONE TIME, Infuse over 90 min, Repeat serum magnesium level 2 hours after the infusion is completed. [serum magnesium level 1-1.2 mg/dl] magnesium sulfate 4 g, IVPB, ivpb, ONE TIME, Infuse over 120 min, [Notify Physician if serum magnesium level less than 1 mg/dl] **Repeat serum magnesium level 2 hours after the infusion is completed. [serum magnesium level < 1 mg/dl - notify physician] Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. ORAL POTASSIUM REPLACEMENT: *****For asymptomatic patients able to take ORAL supplementation***** 20 meq, PO, tab sa, ONE TIME, *Repeat serum potassium level 4 hours after the total replacement is completed. *Check magnesium levels if potassium does not respond after total replacement completed. [Serum Potassium 3.6-3.9 mmol/l] 20 meq, PO, tab sa, q2h, x 2 dose, *Repeat serum potassium level 4 hours after the total replacement is completed. *Check magnesium levels if potassium does not respond after total replacement completed. [Serum Potassium 3.1-3.5 mmol/l] 20 meq, PO, tab sa, q2h, x 3 dose, *Repeat serum potassium level 4 hours after the total replacement is completed. *Check magnesium levels if potassium does not respond after total replacement completed. [Serum Potassium 2.6-3 mmol/l] 20 meq, PO, tab sa, q2h, x 4 dose, [Notify Physician if Serum Potassium less than 2.6 mmol/l] **Repeat serum potassium level 4 hours after the total replacement is completed. **Check magnesium levels if potassium does not respond after total replaceme [Notify Physican if Serum Potassium <2.6 mmol/l] ORAL PHOSPHATE REPLACEMENT: *****For asymptomatic patients able to take ORAL supplementation***** potassium phosphate-sodium phosphate (potassium phosphate-sodium phosphate 250 mg-280 mg-160 mg oral powder for reconstitution) 2 packet, PO, BID, x 6 dose [serum phosphorus 2-2.5 mg/dl] Page 9 of 10
ELECTROLYTE MED PLAN ORAL MAGNESIUM REPLACEMENT: *****For asymptomatic patients able to take ORAL supplementation***** magnesium lactate 168 mg, PO, tab, BID, x 6 dose, Repeat serum magnesium level with AM labs. [serum magnesium 1.3-1.6 mg/dl] Laboratory Potassium Level Phosphorus Level Magnesium Level Page 10 of 10